Working as simulated patient has effects on real patient life – Preliminary insights from a qualitative study

Background: Persons who simulate patients during medical education understand the routines and the underlying script of medical consultations better. We aimed to explore how simulated patients (SPs) integrated this new understanding into their daily life, how this work affected their private life as patients, and what we can learn from these changes for concepts of empowerment. Design, setting, and participants: A qualitative interview study. All SPs of Göttingen medical school who had been working longer than three semesters (n=14) were invited and agreed to take part in an open interview about their daily experience with real doctors. Documentary method was used to identify the main issues. Several cases were chosen according to maximum contrast and analysed by in-depth analysis to provide vivid examples of how simulations may affect the real life of the SPs as patients. Results: Our analysis revealed three main changes in the behaviour of SPs as real patients. They were more attentive, had a better understanding of the circumstances under which doctors work, and acted more self-confidently. From the selected cases it became apparent that working as a SP may lead to a constant and significant decrease of fear of hospitals and medical procedures or, in other cases, may enable the SPs to develop new abilities for giving feedback, questioning procedures, and explanations for real doctors. Conclusion: working as a simulated patient seems to be well-suited to understand own progression of diseases, to increase self-responsibility and to a confident attitude as patient.


Background
Working with simulated patients (SPs) is a widely accepted method for effective teaching and assessment in medical schools [1], [2], [3]. With the help of SPs, students learn manual skills as well as communication skills in a protected environment, including feedback from a patient perspective. SPs as a tool in medical education are welcome by both students and teachers; the effectiveness in teaching has been proven [4]. In addition to many positive effects on medical education, the persons who simulate patients understand the routines and the underlying script of medical examinations better. Previous studies suggest that experiences as SP, especially the activity in role-playing and feedbacktraining, influence the role of the SPs as real patients. Some previous studies have investigated the scope of this influence on a person's behaviour as a patient [5], [6], [7], [8], [9]. Apart from some negative effects such as exhaustion, nervousness, or being displeased with their own efforts, the results showed that SPs develop a more differentiated view on their doctor-patient encounter or that they observe the communication skills of their own general practitioners (GPs) in more detail than other patients do. Moreover, SPs see themselves as more active when communicating with a health-care professional, which speeds up their recovery [10], [11]. Because of the gain in knowledge in medical topics, SPs are also more apprehensive about their own symptoms and disorders [12].

Aims of the study
In addition to previous studies, which predominantly used surveys or focus groups [1], [6], [7], [9], [13], [14] to record changes in the life of an SP, we aimed at exploring in more detail and depth how SPs integrated their new experiences into their daily life, how this work affected their private life as patients, and what these changes teach us about concepts of empowerment.

Context and Sampling
Working with simulated patients as a teaching method was introduced at Göttingen medical school in 2005. Since then, all SPs have been trained and supervised by one of the authors (AS). Similar to most other medical schools, the main components of our SP training are communication skills such as history taking, breaking bad news, or counselling and risk-communication as well as assessment in objective structured clinical examination (OSCEs) and the medical school admission-procedure [1], [4], [15]. To ensure that the study participants had professional skills, we only invited the 14 SPs who had been working with third-and fourth-year students longer than three semesters and in addition had attended OSCEs at least four times per semester. They all agreed to take part in our study. All participants had to give written informed consent; it was possible to withdraw this at any time. The ethics committee of the University of Göttingen approved the study protocol (no 12/4/08).

Data collection
To stimulate narratives of how the SPs dealt with their work, we developed an interview guide using open ended questions focusing on three main areas: 1. poor and good elements in our lessons, 2. teaching of the doctor-patient relationship in our course, and 3. the SPs' experience with their real doctors.
In this paper we focus on the third area. All interviews were conducted by the same person (TL). After a short introduction of the study aim, we created a relaxed and familiar atmosphere to give the participants the opportunity to narrate their experiences. If the participants did not address the third question of their own volition in the course of the interview, they were asked: "What happens when you are a patient in real life? Please tell me about your daily experiences". After piloting the interview changed slightly. TL conducted all the interviews, they were audio-taped and transcribed verbatim; participants were pseudonymised.

Data analysis
The semi-structured interviews should consider the main points of the interview-partners, so the documentary method according to Bohnsack [16] , [17] seemed to be the best approach. The advantage of this method is the possibility to asses both -without methodological limitations -the broadness of topics and also the implicit ideas which are underlying the spoken words. The interviews were analysed in two ways: 1. To analyse central topics mentioned in the interviews, we used the first step of the documentary method according to Bohnsack, his concept of "formulating interpretation". After reading each transcript, all narrations were summarized, and main topics as well as sub-topics were formulated using an inductive approach. This step refers to the content of the interview and provides a broad overview of what was said in the interview. 2. On the basis of the first step of analysis, we then identified several cases that represented quite distinct ways of "handling the work as a SP according to maximum contrast. These passages were analysed with the second step of Bohnsacks approach, the "reflecting interpretation". We concentrated on "how something is said", who was involved in the events, when and where the events took place and which feelings were reported in order to illustrate both different types of SPs and different types of transferring new skills into real-life consultations.

Participants
All eligible SPs (n=14) agreed to take part in the study, nearly all of them were female (12/14). They were between 24 and 70 years old and had been working as SP for between two and six years. The interviews lasted between 20 and 55 minutes and took place in our department or at the home of the SPs.

Experiences of SPs as patients in real life: main topics
In the interviews, the SPs freely talked about their daily experiences as a patient in real life. The many simulated consultations they took part in while they were SPs seemed to have activated a learning process that led to (a higher) awareness of structure, rules, and content of consultations in daily life. Three main topics emerged in our analysis of the SPs' practical knowledge in real consultations with doctors: they were more attentive, had a better understanding of the circumstances under which doctors work, and acted more self-confidently. Although these topics are presented separately here, in daily practice they are closely related.

Being more attentive
Training in simulation and the skills as SP obviously helped our interview partners to better understand the structure of the doctor-patient communication. Within the consultation, SPs no longer only fill the role as a patient seeking for help, but also act as persons who are familiar with attentive evaluation. This attentiveness enabled the SPs to have a critical view of details of the consultation and the GPs' behaviour, which led them to adopt a critical attitude. ) a: simulation as a professional world of its own Maria, 55 years old, formerly worked as the personal assistant of a head of department in the university hospital for many years. She has been working with us for three years. Apart from a little physical handicap she is an active person visiting the "university of the third age". She is also working with the Samaritan emergency hotline for young people. As our interviews showed, many SPs generally described the doctor-patient-interaction as asymmetric. Maria, however, knows the routines of different medical environments very well and showed a sort of familiarity with medical institutions and personnel. This is more than the understanding of doctors other SPs reported in the course of their teaching activities. Instead, personality, professional skills, and teaching activities might all influence and motivate her more pragmatic view on, and a sober description of, doctors: " The intimate knowledge from her professional career-and not empathy with doctors, as found in other SPs-seems to have been the reason she emphasized time as the most valuable and rare commodity in a GP's real life: "…umm, the teaching situation is set up so that the doctor is there for the patient and gives him the chance to express himself and find out what the problem is, which is of course also the goal of any normal office or any visit to a doctor's, but very often the doctor needs to watch the time he's taking, that is frequently very obvious". Barbara (SP3) : working as an SP as "therapy" Barbara, 59 years old, housewife and socially active within her community, has been working as an SP for three years. During the first part of the interview, she did not talk much about private matters and presented herself somewhat like a 'blank slate'. Later in the interview, the analysis revealed that her motivation for becoming an SP was closely related to her painful experiences as a patient more than 30 years ago when she had to have a caesarean. The gynecologist was very insensitive during a teachingsituation in which Barbara was involved (when medical students visited Barbara on the first day post-op). She remembered that the gynecologist shouted loudly, 'now don't make such a fuss!' Barbara imitated the doctor's intonation as closely as possible during the interview situation 35 years later; this illustrates how emotionally disturbing this incident was. These few words from the hospital doctor hurt her for years and prompted fear towards hospitals for a long time: "When I'm telling you this now, my heart still begins to pound wildly and I just feel like blubbing again". Since some of our courses took place in the same hospital in which Barbara had consulted the gynecologist 35 years before, she had to visit the house regularly as an SP. Obviously, both events, the regular visits to the hospital and the SP activity, helped her overcome her fears of the institution: "

Discussion
Working as an SP enabled our interview partners to act more self-confidently in their real lives as patients, made them more sensitive towards a GP's workload and duties, and may even introduce an intense change of the emo-tional state such as a reduction of anxiety. Feedbacktraining and learning new communication skills, similar to the training and work of our SPs, seem to be well-suited to empower patients in consultations with real doctors [18].

SP training as a way to empower patients?
Our results confirm findings from the United States and the Netherlands [10][11][12] where the experience of working as SPs was described in the context of becoming more attentive and critical and consequently feel more autonomous in medical environments. We know from two American studies [10], [13] that SPs acquire verbal skills that enable them to better explain their own perspective and needs in doctor-patient settings. Some of our interview partners also reported this learning process. As a result, they felt able to direct doctor-patient interactions more towards their own problems. This raises the question of whether there is a "need to worry for GPs, because they face 'supercritical' patients".
In some instances, SPs apparently drew severe consequences, as reported by Woodward and Glivia-McConvey [13]: Some changed their GP after beginning working as SP, but the analysis of the interviews in our study did not show any similar consequences. On the contrary, our SPs-analogously to what was reported , had developed a better understanding of workload and pressure of time that physicians are exposed to, which surely is an effect of the better insight into the every-day work of GPs through the teaching situation. Moreover, as one SP suggested, it may also be a good idea to give feedback to doctors if they act insensitively. This kind of "education" of an insensitive GP was obviously successful in her case. Our analysis did not show any negative effects on the well-being of the SPs. This is in contrast to the Dutch studies performed by Bokken [19] and colleagues, who detected exhaustion and/or physical complaints as a "side-effect" of simulation. The reason for these different results may be that our SPs had comparatively easy role plays and were trained and focused especially on history taking. They were neither physically examined nor required to perform complex clinical cases. Training SPs and working as SPs may be a model of how to become an empowered patient. The results of our study highlight important components of this training and work, such as becoming more attentive and critical and feeling more autonomous in medical environments [20]. In addition, our SPs acquired verbal skills that helped them to better explain their own needs in clinical settings, and they learned to give feedback.

SP and real-life patient
In spite of identical training, the teaching activities of Barbara, Lisa, and Maria led to different consequences in their daily lives: 1. Barbara's case (working as an SP as a psychosocial therapy) shows a constellation that to our knowledge has not been described to date: a traumatic event that causes fear of and aversion to hospitals was changed by her time as an SP. Barbara transformed this negative event into a motivation to be part of a teaching team in a medical school, obviously a successful coping strategy to overcome her fears. It is important to emphasize that it was not this negative event that motivated Barbara to become an SP, but the job helped her in the real life as a patient, and this made her SP activity more important to her. 2. Lisa represents another type of SP: educator even outside the medical school. As a highly skillful patient, she had the motivation to transport her expertise into her everyday-life (outside the medical school). The quality standards she learned during teaching lessons should be also standard in her real relationship with physicians. This type of SP sets out to change the students' as well as a doctor's behaviour, not only for short duration, as described by Rubin [9], but lastingly. Lisa's behaviour also corresponds to the proactive engagement with clinicians as a strategy for empowerment in the "patient-as-professional" model [21]. For example, one patient in an Australian study, which explored this model, described how she always had to keep her GP informed all the time and questioning about her medication and, in the end, to manage the health care team [22]. Other SPs in our study seemed to act similarly in the world outside the medical school. It is only a marginal remark in the context of our study that even a person who feels self-confident in the life-world, like Lisa does, obviously needs the training and experience of an SP to become self-confident in the world of medicine. 3. Maria's motivation to work as an SP (simulation as a professional world of its own) lacks an intimate touch. It seems first and foremost based on a pedagogic ethos, probably originating in her medical background. Consequently, she reported only few personal events and distinguished between the teaching situation and being a patient in real life. She did not feel influenced in her own role as patient by her teaching knowledge and vice versa. But she emphasized more strongly than anyone else the need of teaching communicative skills. Maria's interview was not so much a narrative but an argumentative and rational presentation, more from the perspective of an expert than from that of a patient. She reported in unemotional language that some GPs in her experience lack communication skills or a GP's time constraints are barriers for a strong patient-clinician relationship. This can be interpreted as Maria's way to demonstrate herself as a sort of 'professional SP' or 'patient-as-professional' [21] including the 'duty' to share one's knowledge with others [13], [14], [23], which emphasizes the social context of empowerment.

Strengths and weaknesses of the study
The interviews used open-ended questions, which afforded our interview partners the opportunity to set their own focus on facts and experiences that were relevant in their work as SP and in their real life. Data analysis with a multi-disciplinary team provides a good basis for detecting and examining relevant events and experiences. While we certainly have a complete picture of our own SP staff, the results are not representative for SPs in Germany. Training and teaching in other medical schools may be different and, thus, the knowledge of SPs in other settings and the consequences for their life may likewise be different. The sampling of our interview partners and analysis did not follow the concept of theoretical sampling, so that we cannot be certain to have reached data saturation [24]. Moreover, our interview partners were self-selected and may have been inclined to report in a positive manner.

Conclusions and implications for practice
Personal background, experiences, and motivation of SPs were mixed to various degrees, but were predictably different for each SP. Role-playing may support acting more self-confidently or improve the understanding of doctors, or it may motivate SPs to share knowledge, insights, and ideas with others, as in the case of Maria. As we know from other studies [17], fear, ignorance, and reluctance to ask the doctor are general emotions patients experience in their medical consultations. Instead of appealing to doctors to act more patient-oriented, the training in our course may be a model not for SPs alone, especially the part of becoming familiar with the rules of good (and poor) communication and giving professional feedback. The changes described in this as well as in other studies could also be read as one way to enact the 'patient-as-professional' concept [22] with the aim to empower patients and guide their relation and communication with healthcare professionals [19].
If the empowerment of SP through their job also is true at other locations, this knowledge should be used in casting and teaching situations. SPs and trainer should know about these findings and then would be able to include them during SP-training. Working as an SP seems to empower patients. Future research should explore how some of the SP teaching components can be transferred into other educational settings to support and train real patients who are interested to take a more active role in health care consultations.